Published: 12/08/2004, Volume II4, No. 5918 Page 18 19

The feature 'Beyond the fringe' (pages 28-29, 22 July) served no useful purpose whatsoever for NHS clinical managers or anyone else. It was nothing more than an ill-founded attack on UK chiropractors.

Chiropractic is not a 'treatment' nor is it just 'spinal manipulation'. Chiropractors are statutorily regulated primary healthcare professionals who are qualified to undertake evidencebased management, including a whole package of care, for patients with a range of musculoskeletal conditions.

The research cited in the article is consistently quoted negatively so as to cast doubt on chiropractors. An impartial reading would not lead to the constructions put forward by author Edzard Ernst.

For example, the recent Cochrane review concludes that manipulation is one of a number of effective treatments for low back pain, as do the UK and European Commission Acute Low Back Pain Guidelines (see www. backpaineurope. org).

Taken as a whole, the relevant literature concludes that chiropractic as a service for low back pain is cost effective. This is because it keeps people out of hospital while using effective interventions.

Associating spinal manipulation with 'stroke and death' is not supported by research evidence as a causal relationship.

Typically, a 'significant risk' for any therapeutic intervention is defined as one in 10,000. There are a variety of estimates of incidence of strokes associated with neck manipulation (as undertaken by doctors, osteopaths and physiotherapists as well as chiropractors) ranging from one in 400,000 to between three and six per 10 million manipulations.

Margaret Coats Chief executive and registrar General Chiropractic Council